Inside Duke Medicine

Duke Children’s reduces catheter infections

It is said a journey of a thousand miles begins with a single step.

Duke Children’s Hospital & Health Center could say the same about its significant success in reducing catheter-associated bloodstream infections (CABSI).

The single step that launched the center’s journey to improve patient safety, reduce hospitalization time and decrease CABSI-related costs was a 2006 decision for its pediatric intensive care unit to join a 29-member, three-year national children’s hospital collaboration to tackle the central catheter line infection issue.

The goal was more than following best practices. It was proposing and establishing best practices to combat a problem that affects tens of thousands of patients annually at a cost to hospitals of $30,000 to $35,000 per episode. An average of 12 to 25 percent of the infections are fatal.

“There had been no pediatric research yet. We were the research. We were the beginning, and we have rolled out our success to the rest of Duke Children’s and now to the rest of the hospital,” said Rebecca Ellis, RN, CCRN. “It’s a big deal now, and it started with us.”

The success shows. CABSI rates - measured both in the number of cases per month and as a percentage of patient catheter line days per month - have decreased 50 percent since October 2006. More important, the improvement has been sustained over time.

In order to build on that improvement, the entire Children’s clinical service unit recently began an infection-prevention campaign that focuses on hand hygiene as well as insertion and care/maintenance of central lines. All pediatric disciplines participated in the educational effort.

Physicians, staff and patients were encouraged to “raise their hand” for infection prevention by decorating a hand cut-out with their name on it - to show their support for infection prevention. A slogan contest and arts and crafts activities for patients educated them on the importance of hand hygiene in preventing infections. Pediatric patients also got stickers to give to staff reminding them to wash their hands.

“The first biggest step is consistent handwashing before and after every patient contact,” Ellis said, also citing use of sterile gloves, masks and gowns for central line care. “A lot of our patients have central lines and these infections are very preventable. We do surveys of our nursing practice every week to ensure it’s all done properly.”

When the standardized practices began, PICU nurses were trained in one-on-one sessions. To further ensure consistency as the staff changed (and expanded with the January addition of the pediatric cardiac ICU), the sessions now are held every six months.

CABSI and other hospitalacquired infections are attracting the attention of private and government insurance programs, which are moving toward not reimbursing costs associated with such infections.

But proactive involvement in the national collaboration has put Duke Children’s in an advantageous position. Not only has the PICU shown sustained improvement in CABSI rates, but patient care units across Duke Children’s Hospital also are seeing reductions in CABSI rates. The overall CABSI rate for the clinical service unit is 49 percent below target year to date.

A case in point: The new pediatric cardiac ICU has seen no CABSI cases since it opened on Jan. 6.

“That’s huge. We’re celebrating,” Ellis said, crediting the work of the bedside nurses in maintaining the catheters after insertion. “The major problems can involve maintenance because our critically ill children stay in for weeks and months, so the catheters also stay in for weeks and months.”

While most of the PICU and PCICU work focused on central line maintenance, care for adult patients in Duke University Hospital focused on central line insertion.

Michael Alton, administrative director of performance improvement for Duke Children’s, echoes Ellis’s sentiments.

“The improvements we’ve seen in our CABSI rates are directly linked to the frontline staff leadership we’ve had in this initiative,” Alton said. “They’ve developed solutions based on the collaborative’s recommendations, worked with their clinical teams to make those solutions a reality, and continued to refine their practice based on lessons learned. And that effort has really paid off for our patients.”

“There’s no better indicator of our commitment to outstanding patient care and the highest standards of treatment than this exceptional effort to reduce catheter-associated infections,” said Joseph   W. St.Geme III, M.D., chairman of the Department of Pediatrics and chief medical officer of Duke Children’s Hospital and Health Center.